Volunteer Services

Volunteer Services

Colquitt Regional Medical Center

P.O. Box 40 * Moultrie, GA 31776

(229) 891-9181

Dear Prospective Youth Volunteer (YoVo),

Thank you for your interest in Colquitt Regional Medical Center’s Youth Volunteer Program. Below you will find detailed information and requirements for our program.

Minimum Qualifications for Participating in the program:

• Must be at least 14 years of age, entering into the 9th grade as a full time student to 18 years of age as a full time senior student.
• Have a GPA of 3.0 or higher. (“B” average)
• Provide a reference from a current teacher or school guidance counselor using the enclosed form.
• A mature individuals with potential interest in pursuing a career in healthcare.

Application Procedures:

 Application: Complete the enclosed application, background check form and consent for protected health information.

 Take to school: permission for release form signed by a parent/guardian and student AND reference form (and envelope) to be completed by a teacher or counselor. Teacher/Counselor recommendation should be sealed.

 Return the above applications, forms and teacher/counselor reference to :

• Volunteer Services Office, located in Marketing / Foundation Suite on 1st floor of hospital or mail to: Volunteer Services @ CRMC, P.O. Box 40, Moultrie GA 31776

 We will review your information; if you meet our requirements then we will contact you about attending a group interview meeting which is held monthly. At this meeting, we will discuss expectations and benefits along with a touring the hospital. (Parents are welcomed to attend but it’s not required)

If accepted into this program, you will then be required to:

• Clear a criminal background check. (please sign the form enclosed)
• Have a health physical, including a drug test, and TB skin test by Colquitt Regional Medical Center’s Employee Health nurse.
• You must bring a copy of your last immunization records and your parent MUST attend this with you when scheduled.
• Attend hospital orientation and take a quiz regarding hospital safety and quality measures.
• Be available to work a minimum of one shift (4-5 hours each) per week. Note, some shifts may only be available on weekends and evenings, for example from 4pm – 9pm.
• Become CPR certified (this will be paid for by a grant provided by United Way of Colquitt Co.)
• Attend a monthly YoVo meetings.

Note: Please understand the number of students accepted to participate depends on the number of available service positions.

Sincerely,

Nicole Gilbert

Volunteer Services Director

Colquitt Regional Medical Center

Youth Volunteer “YoVo” Application

[print]

NAME ______

LAST FIRST

ADDRESS ______CITY ___ _ ZIP ____

(____)______(____)______

Home Phone Cell Phone

Email: ______SS# ______

Birthday____/____/____ CIRCLE Shirt Size S, M, L, XL & Pant Size S, M, L, XL

School ______Grade ______Year Graduating: ______

SPECIAL INTERESTS, HOBBIES, SKILLS OR SPECIAL TRAINING:

(i.e., COMPUTER SKILLS, CASH REGISTER, ETC. ______

______

______

SCHOOL & COMMUNITY ORGANIZATIONS: ______

______

______

DATES UNABLE TO VOLUNTEER:

______

IN CASE OF EMERGENCY NOTIFY:

______Home # (___) ______

Parent or Guardian Relationship

Work# (___) ______

Cell # (___) ______

PLEASE WRITE A PARAGRAPH ABOUT YOURSELF AND WHY YOU THINK YOU WOULD BE A GOOD VOLUNTEER.

______

______

______

______

______

______

______

______

______

______

______

______

SIGNED BY YOUTH:

If accepted into the Youth Program at Colquitt Regional Medical Center, I understand the importance of giving courteous care and friendly aid to patients, hospital staff and visitors. I will accept assignments cheerfully and willingly, will be prompt for duty and will ask another youth volunteer to work in my place when it is necessary for me to be absent. I understand that three unreported and unexcused absences will be considered as an indication of my lack of interest, and that I will be dropped from the program.

Signature______Date______

SIGNED BY PARENT or GUARDIAN:

My child, ______, has my consent to serve as a youth volunteer at Colquitt Regional Medical Center and I will support the above stated responsibilities if accepted.

Signature______Date______

Complete this form and give to your teacher / counselor

along with the Reference Form and an envelope.

Permission for Release of

Confidential Information Form

I give permission for the release of any information and/or records pertaining to my grade point average (GPA) and conduct record from the school listed below:

______SCHOOL

______

SIGNATURE OF STUDENT

______SIGNATURE OF PARENT OR GUARDIAN

Colquitt Regional Medical Center

Youth Volunteer Program

Reference Form

______has applied to be a youth volunteer at Colquitt Regional Medical Center. Please complete the reference form below and the additional comments section. The “Permission for Release of Confidential Information”, signed by the applicant and a parent or guardian, is attached.

****************************************************************************

1.Overall Scholastic Grade Point Average______

2.Is student’s overall conduct satisfactory? ______

3.How long have you known the applicant? ______

4.Please check the rating which best represents your impression of the applicant:

Excellent Good Satisfactory Poor Personality ( ) ( ) ( ) ( )

Dependability( )( )( ) ( )

Maturity( )( )( ) ( )

Assumes Responsibility( )( )( ) ( )

Works Well With Others( )( )( ) ( )

Respects Authority( )( )( ) ( )

Follows Directions( )( )( ) ( )

5.Additional comments ______

______

______

______

______

Signature of Teacher or Counselor Date

PLEASE USE ATTACHED ENVELOPE AND INITIAL ON THE SEALED FLAP. RETURN TO STUDENT.

Criminal Background Check Authorization

Colquitt Regional Medical Center

I, the undersigned, hereby authorize Colquitt Regional Medical Center to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal junction agency.

Please read and acknowledge by initialing below:

_____Failure to list all information on criminal charges, pending charges, and/or convictions will result in your request to volunteer be withdrawn.

_____Pleas of nolo contendere or nolle processed must be listed.

_____Charges processed under Georgia’s First Offender Act are not required to be listed IF all requirements have been met. (e.g. fines paid, community service, probations, etc. have been completed)

_____ If unsure of status, please discuss with our Human Resources office prior to signing this form.

_____Note: DUI’s cannot be processed under Georgia’s First Offender Act, and all DUI convictions, nolo pleas or pending charges must be listed.

I am stating one of the following:

_____I have been convicted of a violation of any federal, state, county, or municipal law, other than minor traffic violations. Please list below:

______

______

______

_____I have NOT been convicted of a violation of any federal, state, county, or municipal law, other than minor traffic violations.

Also, please check ONE:

_____I have NEVER been shown by credible evidence (e.g. court of jury, a department investigation, or other reliable evidence) to have abused, neglected, or sexually assaulted, or exploited, or deprived any person or to have a subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral written statement to this effect obtained at the time of my application.

_____I have been shown by credible evidence (e.g. court of jury, a department investigation, or other reliable evidence) to have abused, neglected, or sexually assaulted, or exploited, or deprived any person or to have a subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral written statement to this effect obtained at the time of my application.

______

Applicant SignatureDate

[revised 11/6/07]

Colquitt Regional Medical Center

Human Resources

3131 South Main Street

PO Box 40

Moultrie, Georgia 31776

(229)890-3533

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by MBI Worldwide, Corporate Headquarters, 101 North Park Drive, Suite 200, Herrin, IL 62948, (866) 275-4624, , another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.
Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. □
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. □

BACKGROUND INFORMATION

Please print/type the requested information. Lack of legible or missing information may delay processing of this request.

Applicant Name: ______

LastFirstMiddle

Other names known by (Including Maiden)______

Present Address: ______

Street CityStateZipCounty

Date of Birth: ______/______/______Driver’s License # ______State______

(MM/DD/YYYY)

SS#: ______Male / Female (Circle One) Race ______

Home Addresses for the Past 7 Years: (List additional addresses on separate page, if needed.)

Street Address City State/Zip County Dates Mo/Year

______

Phone Number: . We may need to contact you for additional information or to clarify information on this form.

(Area Code) + Telephone Number

This information will be used for background screening purposes only and will not be used as hiring criteria.

Signature: Date:

[PARENTAL CONSENT FOR HEALTH SCREENING OF MINORS]

Colquitt Regional Medical Center

EMPLOYEE HEALTH SERVICES

To insure the health and safety of our volunteers, Colquitt Regional Medical Center’s infection control committee requires that all volunteers participate in a free health screening. This screening consists of the completion of a health history form, drug screening, a copy of the minor child’s immunizations record and a tuberculosis skin test.

I, as parent or legal guardian of said minor child, and acting on his or her behalf, hereby release and discharge Colquitt Regional Medical Center and Employee Health Services from any and all claims of injury or liabilities of any administration, test processing, screening or any act or omission arising there from or related thereto. I understand the possible adverse reactions and consent for said child to have a health screen and tuberculosis test. I further understand that if the tuberculosis skin test is found to be positive, this information will be forwarded to Colquitt County Health Department and it is my sole responsibility to arrange for additional medical evaluation and treatment for these findings.

As legal guardian I give consent to Colquitt Regional Medical Center to perform medical treatment of my child if required while performing volunteer duties within the hospital. In the event of a medical emergency, I permit the attending physician in the emergency Center of Colquitt Regional Medical Center to treat my child if required while performing volunteer duties within the hospital.

Name of Child ______SS#______

Parent/Guardian (print name) ______

Parent/Guardian (signature) ______

Colquitt Regional Medical Center

Consent for Use or Disclosure of Protected

Health Information for Payment, Treatment

and Health Care Operations

By signing below, you hereby consent for Colquitt Regional Medical Center to use or disclose information about yourself (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purposes of treatment, payment and health care operations. You may refuse to sign this consent form.

You should read the Notice of Privacy Practices for protected health information made available to you by CRMC before signing this Consent. The terms of the Notice may change from time to time, and you may always get a revised copy of it by asking the CRMC Privacy Officer or the department/area where you are receiving treatment.

You have the right to request that CRMC restrict how your information is used or disclosed to carry out treatment, payment, or health care operations. PPHS is not required to agree to requested restrictions; if it does, however, the restriction is binding on it.

Your "protected health information" means health information, including your demographic information, collected from you and created or received by your physician, another health care provider, a health plan, your employer or a health care clearinghouse. This protected health information relates to your past, present or future physical or mental health or condition and identifies you, or there is a reasonable basis to believe the information may identify you.

Information about you is protected under federal law, and you have the right to revoke this Consent, unless we have taken action in reliance on your authorization (as determined by our Privacy Officer). By signing below, you recognize that the protected health information used or disclosed pursuant to this Consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law.

I acknowledge by placing my signature in the space provided that I have had access to the Notice of Privacy Practices and Notice of Individual Rights, and have read the above information.

If someone calls or visits and asks about you, can we acknowledge that you’re here?

Yes ____No____

______

Individual SignatureDate

If a minor, this must be signed by parent or legal guardian.

As a personal representative, I have authority to act for the individual because I am the individual’s ______.

Parent or Guardian Signature

Why YoVo?

There are many benefits to participating in Colquitt Regional Medical Center’s Youth Volunteer Program. Listed below you will find just a few …..

• Free meal in the cafeteria during your shift.
• Community service looks GREAT on a college application.
• Letters of reference from hospital CEO based on your performance.
• College scholarships.
• Real work experience in the department of your choice.
• Learn communication and leadership skills.
• Make a great connection in your local community.
• Recognition at Senior Honors Night at CCHS.
• Other gifts & surprises throughout the year at our monthly YoVo meetings.

Hours Volunteered + 3.0 GPA = Scholarship!

There are four levels at which you will be rewarded for your service based on the hours you volunteer here at Colquitt Regional. With a 3.0 GPA at the end of your Senior Year, you will be honored at Colquitt County High School’s Senior Honor’s Night your graduating year. So, you have until you graduate to accumulate your hours!

Platinum Volunteer 750 hours$1,500 Scholarship

Gold Volunteer 500 hours$1,000 Scholarship

Silver Volunteer 250 hours$500 Scholarship

Bronze Volunteer 125 hours$250 Scholarship

If you have any questions or need more information, please contact me at (229)-891-9181. I am looking forward to meeting you.

Sincerely,

Nicole Gilbert

Foundation Director/Volunteer Director

Colquitt Regional Medical Center

VOLUNTEER CHECKLIST

 Application (2 sheets)

 Be sure you and your parent/guardian have signed the form.

 Sealed envelope from teacher or counselor that contains:

 Permission for release of confidential information form

 Reference form

 Criminal Background Form (2 sheets)

 Signed by youth

 Consent for health screening and protected health information (2 sheets)

 Be sure you and your parent / guardian have signed the form.

 Immunization Records. Please contact your physician for a copy. When you are accepted as a youth volunteer and scheduled to meet with our Employee Health Nurse, you will need to bring a copy of your latest immunization record and a parent MUST attend.

Return the above items to our Volunteer Services Office, located in the Marketing / Foundation Suite on the first floor of the hospital.

You may mail to:

Colquitt Regional Medical Center

Volunteer Services

P.O. Box 40

Moultrie, GA 31776

We are looking forward to meet you!

6/2016